The disease of Xu Lao (虚劳) should be classified according to the Nan Jing (难经) into three categories: upper damage, middle damage, and lower damage. The so-called upper damage includes damage to the heart and lungs, which is described as “one damage affects the skin and hair, causing the skin to shrink and hair to fall out”, indicating damage to the lungs; “two damages affect the blood vessels, leading to deficiency and inability to nourish the five organs and six bowels”, indicating damage to the heart. The middle damage is described as “three damages affect the muscles, leading to muscle atrophy and inability to nourish the skin”, indicating damage to the spleen. The lower damage includes damage to the liver and kidneys, described as “four damages affect the tendons, leading to weakness and inability to hold”, indicating damage to the liver; “five damages affect the bones, leading to bone atrophy and inability to rise from bed”, indicating damage to the kidneys. Furthermore, according to the Jin Gui (金匮), it can be divided into two major categories: “a large pulse indicates labor, and extreme deficiency also indicates labor”. The large pulse and extreme deficiency refer to the pulse but actually discuss the pathogenesis, where “labor with a large pulse is due to excessive worry damaging qi, while labor with extreme deficiency is due to the loss of essence and blood”. The discussions in the Nan Jing and Jin Gui are interconnected; the former is the longitude, and the latter is the latitude. Overall, it indicates deficiency of qi and blood in the five organs. According to the experience of Ye Tianshi, the development process shows that upper damage can affect lower damage, and lower damage can affect upper damage; if it exceeds the middle, it becomes difficult to treat (this is indeed observed clinically). The general treatment principle is: “nourish the deficient”, “benefit the damaged”, and “warm the laboring” (warming refers to nourishing, not merely using warming herbs). Further, treatment is divided according to the five organs, where “for lung damage, benefit the qi”; “for heart damage, regulate the ying and wei”; “for spleen damage, regulate diet and manage cold and heat”; “for liver damage, soothe the interior”; “for kidney damage, benefit the essence”. As for prescriptions, for labor with a large pulse and upper and middle damage, the first choice of herbs is Huang Qi Jian Zhong Tang (黄芪建中汤). This is because “for lung damage, benefit the qi”, and sweet warming herbs can benefit qi, as Ye Tianshi has applied this. For example:
Ren, 56 years old, labor injury to yang, worsened from spring to summer, fatigue, spirit weak and not eating; how could cough medicine cure this? The Nei Jing (内经) states that those who labor should be warmed, and Dong Yuan has sweet warming qi benefiting formulas, which can be considered a definitive method.
Gui Qi Jian Zhong Tang (归芪建中汤).
As for heart damage, the method should be to regulate the ying and wei; why can Jian Zhong Tang (建中汤) also be used? This is because “the stomach is the root of the wei, and the spleen is the source of the ying”. Establishing the middle qi is precisely to regulate the ying and wei. Ye Tianshi often used Jian Zhong with reduced ginger to treat symptoms such as cough due to deficiency labor, hemoptysis, etc., and presented several medical cases as follows:
1. Zhong, chronic cough, spirit weak, and muscle wasting, due to internal injury from labor; the doctor did not differentiate between upper and lower damage, but used bitter cold to descend, qi leaked, sweat was profuse, and fluids were consumed by night heat, appetite was reduced due to bitterness. Used the Jian Zhong method.
Huang Qi Jian Zhong Tang (黄芪建中汤) without ginger.
2. Someone, due to yin damage affecting yang, heat and cold interchanged, should regulate the ying and wei.
Shen Qi Jian Zhong Tang (参芪建中汤) without ginger and sugar.
3. Lü, left pulse thin, right pulse empty and beating. Long-term cough with shortness of breath like wheezing, muscle heat and daily weight loss, indicating internal damage and fear symptoms. However, appetite was poor, and stool was clear; it was necessary to cool and moisten, unable to treat the demand, merely causing injury as if placed. In the past, the Yue people said that upper damage exceeds the spleen, and lower damage affects the stomach, both belong to difficult-to-treat cases. He said he felt cold in the back and sudden heat, and should regulate the heart, ying, lung, and wei. What Zhong said: the original qi is damaged, sweet herbs should regulate it for twenty days. Proposed the Jian Zhong method.
Huang Qi Jian Zhong (黄芪建中) without ginger.
From Ye’s medical cases, it can be seen that the application of Jian Zhong Tang has the following indications:① long-term illness with weight loss and fatigue; ② poor appetite; ③ alternating cold and heat; ④ shortness of breath and easy sweating; ⑤ weak and powerless pulse, not rapid; ⑥ history of excessive labor.
Conversely, if there are signs of yin deficiency and internal heat, Jian Zhong Tang should not be used, only Zhi Gan Cao Tang (炙甘草汤) can be used. For example, in the Lin Zheng Zhi Nan (临证指南) case of Xu Lao:
Someone, pulse weak and thin, night heat, morning cold, fatigue, thirst, sweating, and organ yin has been depleted; in spring, qi leaks outward, according to the Nei Jing, if the original qi is damaged, sweet herbs should be given.
Yin deficiency should use Fu Mai Tang (复脉汤) (which is Zhi Gan Cao Tang (炙甘草汤)).
Zhi Gan Cao, Ren Shen, E Jiao, Huo Ma Ren, Sheng Di, Mai Dong, Gui Zhi, Bai Shao.
For spleen damage, one should regulate diet, manage cold and heat, and using Jian Zhong Tang is more reasonable. Other formulas for tonifying the spleen include Gui Pi Tang (归脾汤) and Bushi Yiqi Tang (补中益气汤), which are also commonly used. The difference in application of these two formulas is summarized by Wang Xugao: “thinking and worrying injures the spleen’s ying, while labor injures the spleen’s qi. Gui Pi Tang nourishes the spleen’s ying; Bushi Yiqi Tang nourishes the spleen’s qi.”
The labor with an extremely weak pulse is often due to the loss of essence and blood, indicating lower damage to the liver and kidneys. In the Jin Gui chapter on Xu Lao, although there are formulas for treating the liver such as Suan Zao Ren Tang (酸枣仁汤) and for treating the kidneys such as Shen Qi Wan (肾气丸), the former only treats one syndrome of the liver (insomnia due to deficiency and restlessness), while the latter can only warm and strengthen kidney yang but cannot replenish kidney essence. The Jin Gui discussions on liver and kidney lower damage are evidently incomplete, but later generations have made significant developments in tonifying the liver and kidneys. In summary, the methods for tonifying the liver are: first, nourishing the liver, as the liver stores blood; tonifying blood is how to nourish the liver, with Dang Gui (当归), Gou Qi Zi (枸杞子), and He Shou Wu (首乌) being commonly used herbs, with a decoction being a representative formula; second, restraining the liver, as the liver is nourished by sour flavors, with Yi Zhi Ren (益智仁), Bai Shao (白芍), Mu Guo (木瓜), and Wu Mei (乌梅) having restraining effects on the liver; third, soothing the liver, as the liver is often urgent, sweet foods can soothe it. Gan Mai Da Zao Tang (甘麦大枣汤) contains three sweet ingredients, which align with the principle of “soothing the interior for liver damage”. Although the herbs are mild, adding Bai Shao and Yi Zhi Ren can treat the liver’s loss of softness, and it often yields remarkable effects. Ye Tianshi stated, “spicy regulates, sour treats the liver, and sweet soothes urgency,” where the latter two belong to the methods of tonifying the liver. For kidney damage, the Nan Jing has already clearly pointed out that it is necessary to benefit the essence. Therefore, Ye Tianshi often used nourishing and replenishing methods, with Fu Mai Tang as the main formula, adding He Che (河车), Gui Lu (龟鹿), and blood and meat products such as pig and sheep spinal marrow to cultivate essence and blood; supplemented with gentle herbs like Hui Rong (灰蓉), Gou Qi Zi, Tu Si Zi (菟丝子), Tong Ji Li (潼蒺藜), and Ba Ji Tian (巴戟天). However, when using these herbs, one must pay attention to the patient’s appetite.
From this, it can be seen that the major method for treating Xu Lao is to differentiate between yin injury and yang injury, and also to observe the upper, middle, and lower symptoms. For yang injury, Huang Qi Jian Zhong Tang is the main formula, while for yin injury, Fu Mai Tang is the main formula. For cases of lower damage with good appetite, filling yin herbs can be used; if there are already symptoms of “reduced appetite, loose stools, nausea, abdominal pain, and dual qi injury, then it becomes urgent” (as stated by Ye Tianshi), Jian Zhong Tang should be used.
It should also be noted that the disease of Xu Lao is often confused with what later generations call labor tuberculosis, which corresponds to pulmonary tuberculosis. While it can certainly be included under Xu Lao, the methods for treating Xu Lao in the Jin Gui cannot be entirely applied to treat labor tuberculosis. In this regard, Mr. Cheng Menxue’s article Xu Lao Jie (虚劳解) elaborates, and I will briefly summarize its main points and provide a translation as follows:
When discussing Xu Lao, it is essential to clarify that if one uses the major methods for treating Xu Lao in the Jin Gui to treat all recent cases of hemoptysis, cough, and labor disease, there is a 90% chance of failure, as Xu Lingtai commented accurately on Ye Tianshi. Ye Tianshi used Xiao Jian Zhong Tang (小建中汤) to treat labor damage, and about nine out of ten patients responded positively. Xu Lingtai said:“The ancient people referred to labor disease, which is not the same as the modern understanding of yin deficiency with heat. If Gui Zhi is taken, it will lead to death if yang is excessive. For cough, taking raw ginger will certainly lead to hoarseness.”
(Note: Ye Tianshi often reduced ginger in Jian Zhong.) As for Huang Yuan Yu and Chen Xiu Yuan treating Xu Lao, they fundamentally disregard nourishing yin and clearing methods, either using Gui Fu or Shen Qi, ignoring everything else, believing it to be the method of Zhong Jing, but in reality, it is a case of lung and kidney yin deficiency, with the fire of the monarch and minister being inflamed, which can be seen at any time. If Gui Fu is used, it will lead to the risk of heat herbs consuming yin fluids; even using Shen Qi also violates the taboo of assisting qi and generating fire. Those who lean towards nourishing yin view all labor diseases as yin deficiency, excessively using bitter cold, damaging the vital yang; this is certainly not in line with the pathogenesis. Conversely, those who lean towards warming and tonifying view labor diseases as yang deficiency, excessively using warming herbs, damaging yin essence and fluids; this is also a form of bias. It is essential to understand that the human body’s qi transformation is fundamentally about yin and yang; when yin is balanced, the spirit is treated. To believe that yang is always insufficient and yin is always excessive is foolish; however, to believe that yin is always insufficient and yang is always excessive, insisting on nourishing yin and balancing yang, is also a rigid viewpoint. Both schools of thought have valid points and shortcomings. These two frameworks must be broken down before examining what the Jin Gui says.
The Jin Gui discusses Xu Lao, with a tendency to emphasize yang deficiency, but it does not ignore yin deficiency labor symptoms, although it does not focus on them. Its main purpose still originates from the Nei Jing. The Nei Jing states, “those who labor should be warmed”, which is often misunderstood as treating labor with warming herbs. In fact, the “warming” in “those who labor should be warmed” does not refer to warming and resolving but to nourishing the organ qi. Therefore, the Nei Jing also states: “those with insufficient form should be warmed with qi, and those with insufficient essence should be supplemented with flavor,” both of which imply nourishment. The Jin Gui expands on the Nei Jing, believing that symptoms of Xu Lao can include both yin deficiency and yang deficiency, and they should not be treated interchangeably. The method of warming those who labor can only be applied to yang deficiency labor and should not be used to treat yin deficiency labor tuberculosis. Furthermore, fearing that later generations may not discern the symptoms, it could lead to misdiagnosis and harm, so several important symptoms of yang deficiency labor are highlighted as examples, indicating that when these symptoms are present, the warming and nourishing method can be used for treatment. Conversely, it should not be used. Among the highlighted symptoms, the main symptoms should be prioritized; the main symptoms are those that must be present, while the secondary symptoms are those that are accompanying. If the main symptoms are not present but only the accompanying symptoms are seen, one cannot conclude that it is yang deficiency labor; if the main symptoms are mostly present, then regardless of whether the accompanying symptoms belong to yang deficiency, it can be treated primarily as yang deficiency, which is an important point to note.
Now, let’s discuss the main symptoms of yang deficiency in Xu Lao.
[Original] The disease of labor has a floating and large pulse, with restlessness in the hands and feet, severe in spring and summer, and recovering in autumn and winter; yin cold essence leaks out, leading to weakness and inability to walk.
[Original] In men, the pulse is floating, weak, and rough, indicating infertility, with clear and cold essence.
[Original] In men, the pulse is weak, deep, and wiry, with no cold or heat, shortness of breath, urgency in the abdomen, difficulty in urination, pale complexion, occasional eye closure, accompanied by epistaxis and fullness in the lower abdomen; this is due to labor.
[Original] In men, a pale complexion indicates thirst and loss of blood, sudden shortness of breath, and a floating pulse indicates internal deficiency.
[Original] Xu Lao with urgency in the abdomen, palpitations, epistaxis, abdominal pain, dream loss of essence, and soreness in the limbs, with restlessness in the hands and feet, dry throat, and dry mouth, is treated with Xiao Jian Zhong Tang (小建中汤).
[Original] For loss of essence, the lower abdomen is wiry and urgent, with cold in the yin area, dizziness, hair loss, and an extremely weak and thin pulse, indicating loss of essence, loss of blood, and loss of essence.
[Original] The pulse is thin and slightly tight, indicating loss of essence in men, and in women, dream intercourse; treated with Gui Zhi Jia Long Gu Mu Li Tang (桂枝加龙骨牡蛎汤).
The above several points all discuss the diagnosis and treatment of yang deficiency Xu Lao. The cause of deficiency is either loss of blood or loss of essence, so both are mentioned together. Loss of blood and loss of essence can both have yang deficiency and yin deficiency. The above discussion refers to the loss of blood and essence due to yang deficiency, with the main symptoms being in the lower body rather than the upper body, such as cold in the yin area (cold in the lower body), essence leaking out, clear and cold essence, lower abdominal pain, lower abdominal urgency, abdominal pain, loss of essence, pale complexion, and floating and large pulse, all of which are evidence of yang deficiency due to loss of blood and essence. Due to the loss of blood, the warmth of the blood qi dissipates, and with the loss of essence, the true yang in the kidneys is also lost. When yang essence is lost, essence cannot generate qi, qi cannot warm the blood, and blood cannot store the spirit, leading to labor. Among all the symptoms, the main symptoms are especially cold in the yin area, cold essence, abdominal pain, loss of essence, and a weak pulse. If any of these are present, it can be concluded as yang deficiency Xu Lao, and the warming and nourishing method should be used. Because epistaxis is due to yang deficiency and blood not returning to the channels, not due to yin deficiency and internal heat forcing blood upward; eye closure is due to clear yang not rising, not due to yin deficiency and liver yang rising; restlessness in the hands and feet is due to floating yang, not due to yin deficiency and internal heat; dry throat and dry mouth are due to yang deficiency and fluids not rising, not due to yin deficiency and insufficient fluids. Although heat symptoms are present, they are false heat, and the treatment method should still focus on warming and nourishing. In summary, when both main and accompanying symptoms of yang deficiency are present, it is easy to use medication; if symptoms of cold and heat are mixed, one should differentiate between the main and accompanying symptoms and discern their authenticity. Accompanying symptoms should follow the main symptoms, and false symptoms should be discarded; this is the true practice of differentiating symptoms for treatment.
Next, let’s discuss the treatment ofyang deficiency, which can be divided into two levels:light cases use Jian Zhong, while severe cases use Shen Qi.Jian Zhong uses Gui Zhi to benefit the warmth of the blood, Bai Shao to harmonize yin and restrain false heat, ginger and jujube to warm the middle, and sweet syrup to nourish the earth. If symptoms of abdominal urgency and pain, restlessness in the hands and feet, dry throat, and dry mouth are present, it is suitable. This is a method of nourishing yang and harmonizing yin. If there are also symptoms of nocturnal emissions and epistaxis, Gui Zhi Jia Long Gu Mu Li Tang can be combined to restrain the floating yang. If the deficiency symptoms are more severe, Huang Qi Jian Zhong can be used to enhance its qi benefiting power. Shen Qi Wan is used to benefit kidney yin, with Gui Fu to warm kidney yang; if symptoms of low back pain, lower abdominal tightness, difficulty in urination, cold in the yin area, and clear and cold essence are present, it is suitable. Shen Qi Wan is for kidney yang deficiency, where yang essence is not warm, and kidney qi is a method of supplementing both yin and yang, because if only yang is supported, there is no yin to transform; if only yin is supported, there is no yang to generate. However, in patients with more severe yang deficiency, the yin-nourishing ingredients in the formula should be reduced to avoid counteracting the warming effect of yang; at this time, Tian Xiong San (天雄散) is more appropriate. Tian Xiong San benefits fire and generates earth, warming essence and blood; it is a strong agent for tonifying yang, and should not be used recklessly unless the diagnosis is accurate. The above is a general overview of the differentiation and treatment of yang deficiency Xu Lao according to the Jin Gui.
The ancient explanations ofyang deficiency Xu Lao treatment emphasize the aspect of warming those with insufficient form with qi, with only Zhong Jing’s Dang Gui Sheng Jiang Yang Rou Tang (当归生姜羊肉汤) using the rich flavor of lamb to replenish essence as a unique treatment. In fact, “essence generates qi, and qi returns to essence,” the method of replenishing essence is also indispensable for treating Xu Lao. The method of replenishing essence should focus on flavor, thus the Nei Jing states, “those with insufficient essence should be supplemented with flavor” and “those with insufficient form should be supplemented with qi,” both of which are not biased. If discussing labor tuberculosis and similar diseases, then replenishing essence is even more important than warming qi. Therefore, later generations of famous doctors often use blood and meat products, with commonly used formulas such as Gui Lu Er Xian Jiao (龟鹿二仙胶), Quan Lu Wan (全鹿丸), and other similar nourishing formulas being representative.
For the treatment of Xu Lao, one should first use herbal and mineral medicines to warm qi, followed by blood and meat products to replenish essence; this is the comprehensive method. Merely using one approach is not sufficient.
Next, let’s discuss the diagnosis and treatment ofyin deficiency Xu Lao:
[Original] Xu Lao with restlessness and inability to sleep is treated with Suan Zao Ren Tang (酸枣仁汤).
This is the diagnosis and treatment of yin deficiency Xu Lao. In yin deficiency, yang is excessive, leading to heat; thus, Zhi Mu (知母) and Zhi Gan Cao (炙甘草) are used to clear heat and nourish yin. This formula uses Suan Zao Ren (酸枣仁) as the main herb, as it is indicated for restlessness and inability to sleep, due to insufficient yin fluids, leading to the heart not storing the spirit and the liver not storing the soul; when the spirit and soul cannot be stored, restlessness and insomnia occur, thus Suan Zao Ren is used to restrain fluids and store the soul as the monarch herb. Suan Zao Ren combined with Zhi Mu clears heat and nourishes yin, treating the yin deficiency; Suan Zao Ren combined with Zhi Gan Cao harmonizes and transforms yin, treating the deficiency heat. The addition of Fu Ling (茯苓) and Chuan Xiong (川芎) is particularly clever, as yin deficiency leads to excessive fire, consuming fluids and creating phlegm, which obstructs the middle and is also a cause of restlessness and insomnia. Fu Ling eliminates phlegm without being drying; Chuan Xiong can soothe the qi of the liver and gallbladder. By transforming the phlegm and relieving the qi, the yin fluids are replenished, and the restlessness is resolved. The principle is that to transform phlegm, one must clear the fire; to clear the fire, one must nourish the yin.
This method in the Jin Gui can be considered a golden needle for treating the heat of yin deficiency labor.
The Jin Gui discusses Xu Lao, with a bias towards yang deficiency; when discussing yin deficiency, although there is only this one formula, it serves as a demonstration in principle and method. Later generations have made significant developments in treating yin deficiency labor tuberculosis, generally focusing on the upper damage starting from the lungs and the lower damage starting from the kidneys. From the upper damage, it begins with cough and then red phlegm; from the lower damage, it begins with nocturnal emissions and then blood movement. If there is phlegm and blood, the cough becomes more severe; if there is blood movement, nocturnal emissions become frequent. When both essence and blood are injured, the upper and lower are exhausted, and the prognosis is often poor. Furthermore, for symptoms of upper and lower damage, they are both considered “reaching the middle,” and “exceeding the middle” indicates deterioration. Therefore, when labor symptoms are accompanied by loose stools and reduced appetite, it is considered difficult to treat; at this time, only the method of nourishing the soil can be used. However, nourishing the soil must differentiate between yin and yang; the spleen is yin soil and prefers dryness, while the stomach is yang soil and prefers moisture. In cases of yin deficiency labor tuberculosis, when it reaches the “middle,” it often injures yang soil, leading to depletion of stomach yin, a glossy tongue, loose stools, and reduced appetite; one must not use warming and drying methods to nourish the spleen, thinking it will nourish the soil and generate gold. Misusing warming and drying will certainly lead to blood movement and injury to yin, exacerbating cough and red phlegm. At this time, the method of nourishing the soil should focus on clearing and nourishing stomach yin, using herbs like Shi Hu (石斛), Bian Dou (扁豆), Shan Yao (山药), Lian Zi (莲子), Mai Dong (麦冬), etc., which can both nourish the middle soil and avoid the drawbacks of warming and drying. This method is effective and can supplement what previous generations have missed, representing an advancement over previous generations.
There is also the case of blood stasis, which is included under the category of Xu Lao, with symptoms resembling wind bi, where the limbs are numb. The cause of the disease is fatigue and sweating, leading to exposure to a slight wind. Patients often belong to the privileged class, with good nutrition but poor constitution, weak bones internally, and qi deficiency externally; even a slight wind can lead to qi deficiency and blood stasis. The pulse is slightly rough, indicating qi deficiency, and roughness indicates weak blood. The pulse at the cun position is slightly tight, indicating exposure to a slight wind. The ancient method used acupuncture to regulate qi and blood, dispelling the slight wind; if using decoctions, Huang Qi Gui Zhi Wu Wu Tang (黄芪桂枝五物汤) is the best. Gui Zhi and Ying dispel wind, while Huang Qi benefits the wei and secures the exterior; using this method, several doses can lead to recovery. This case is a type of qi and blood deficiency, although it has a separate name of blood stasis, it is not significantly different from other bi syndromes.
The above discussion by Mr. Cheng Menxue on Xu Lao disease is insightful and worth deep reflection. The blood stasis disease appears to be mild, but it is actually difficult to treat. The difficulty lies in the pulse being weak, rough, and slightly tight. Weakness and roughness are not typical of mild diseases, indicating qi and blood deficiency; slight tightness also indicates an evil presence. Although the Jin Gui states, “to harmonize the pulse and remove tightness is to recover,” it is evident that the recovery requires first addressing the harmony of the pulse, but achieving this is not easy. Note that the first point in the Jin Gui highlights the pathogenesis as “weak bones,” indicating that the disease is in the bones. The second point considers acupuncture as the first treatment method rather than decoctions, indicating its suitability for acupuncture. The third point is that this disease is included under the category of Xu Lao for a reason; the reasoning is that it is a difficult-to-treat disease, different from general bi syndromes, hence it is stated as “external symptoms of the body are numb like wind bi.” Furthermore, Jing states: “numbness indicates that the muscles and body are stiff, with pain and itchiness not felt, resembling wind bi, but it is not actually wind.” Dan Xi stated, “ma (麻) belongs to qi and blood deficiency, while mu (木) belongs to damp phlegm and dead blood,” which is credible. In clinical practice, limb numbness is still treatable, but wood (湿) is stubborn and difficult to treat, as damp phlegm and dead blood are mutually binding and not easy to remove. Mr. Cheng stated that this case can be treated with Huang Qi Gui Zhi Wu Wu Tang for several doses to recover, which refers to general muscle and bone soreness and numbness, not true blood stasis.
——Jin Shoushan, Jin Gui Interpretation (金匮诠释)
